Healthcare Provider Details

I. General information

NPI: 1336656537
Provider Name (Legal Business Name): VICTORIA KOCH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 S 42ND ST
MOUNT VERNON IL
62864-6264
US

IV. Provider business mailing address

PO BOX 955860
SAINT LOUIS MO
63195-1048
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-3278
  • Fax:
Mailing address:
  • Phone: 636-498-5944
  • Fax: 618-443-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209016821
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2017038330
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: